Identifying children at risk of malnutrition

 Alan A. JacksonEmail authorView ORCID ID profile

Nutrition Journal201817:84
https://doi.org/10.1186/s12937-018-0392-4
© The Author(s). 2018

 Received: 3 September 2018

 Accepted: 3 September 2018
 Published: 15 September 2018
This issue of Nutrition Journal includes three papers by Grellety and Golden, which
explore comparisons between the use of mid-upper arm circumference (MUAC) and the
use of weight in relation to height (WH) to screen for and identify children with severe
acute malnutrition at risk of death [1, 2, 3]. This important debate is the most recent in a
long history of attempts to understand the nature of a condition of varied geographical
distribution with a complex aetiopathology in which the risk of mortality is high and
effective care needs can appear counterintuitive. The condition is common where
resources are limited and hence identification and effective care requires simple
approaches that can be delivered at community level, but more complex problems need to
be securely identified and manged in a facility [4, 5]. Grellety and Golden [1, 2, 3]
present data that suggest that the current balance of effort allows unacceptable mortality
because groups of children at greatest risk based upon WH or the presence of oedema are
not adequately identified when using MUAC, and hence, not offered appropriate care. If
the authors are correct, the problem needs to be acknowledged in order for better
approaches to be considered and put in place.

One of the great marks of the progress of society over the past 50 years has been the
considerable improvements in the life opportunity for children, marked as significant
reductions in post-neonatal mortality for children under 5 years of age [6]. A wide range
of players can be credited with making contributions to these singular achievements
[4, 5, 6]: contributions which embrace a rights-based approach to health and
consideration of social factors and also the biomedical interventions required to save life
and enable normal development in children at risk [4, 5, 7, 8]. One of the major
challenges in efficiently facilitating progress has been the extent to which the problem of
malnutrition is conceived of as a social problem or a medical problem. The reality is of
course that social progress itself is often manifest as changing patterns of ill-health,
which present as medical problems [4, 5, 9].

Given that malnutrition is prevalent in many widely different contexts [4, 5, 10], its
genesis and any approach to its alleviation has always excited strong differences of
opinion about how it might best be tackled. The priority given to any of the widely
different approaches that might be adopted has often depended upon the particular
interests and direction of concern of those immediately involved. The model articulated
by UNICEF of immediate, underlying, and basic causes acknowledges multiple levels of
concern, each of which has to be the focus and responsibility of different groups, but each
of which has implications for the other levels; therefore, all have to be addressed with
some measure of balance [11, 12]. At times, differences among approaches have evoked
fierce controversies that have challenged our scientific insights, intellectual
understanding, and our ability to translate theory into practice. These uncertainties have
been particularly evident when the problems being addressed appear intractable, and
hence, there is uncertainty about how best to proceed [7]. Further insights based upon
advancement in technology, its application to health care, and the understanding
generated from the available data have enabled resolution of differences, thereby
clarifying the most appropriate approaches that not only embrace differences in
viewpoints but draw strength from their resolution. At its heart, resolution of these
uncertainties and differences reflects the importance of research and its application to the
delivery of improved health care [4, 6, 8]. For example, the development of ready-to-use
therapeutic foods derived from milk-based products for managing severely malnourished
children has been informed by results of physiological and metabolic studies carried out
in hospital, but has enabled a high standard of care in the community [13, 14, 15, 16]. By
applying the same principles, the further development of products based upon locally-
available foods have made possible backward food production and employment
opportunities and a move to local sustainability [17, 18]. The important underlying
principle is that the nutrient composition of the therapeutic food seeks to correct common
specific nutrient deficiencies that are not readily achieved through usual food mixes
[13, 14, 15, 16, 18, 19].

The characterisation and understanding of the pathophysiology of severe malnutrition has

enabled the delivery of better services, both for its care and for its prevention [5]. At
times, contention about the most appropriate approach to adopt has been vitriolic
amongst strong personalities with passionate enthusiasm to improve outcomes. Williams
[20, 21] and Waterlow [22, 23] both had experience characterising and treating the
problem in West Africa and the Caribbean. Williams can be credited with the careful
clinical characterisation of the kwashiorkor syndrome, its differentiation from marasmus,
and its diagnosis, progress and treatment in the Gold Coast, now Ghana [20, 21]. This
enabled others to better structure their clinical approach to care. As a physiologist
clinician, Waterlow drew on the experience of Williams to develop a more secure
framework for scientific investigation [4, 5, 23]. His group showed how modulation of
physiology to achieve reductive adaptation enabled survival of the most nutritionally
challenged, albeit at the risk of decreased resilience to metabolic imbalance or
environmental stresses such as infection or emotional trauma. Applying this
understanding to achieve successful care required carefully structured approaches, as
exemplified in the WHO 10 steps [24], which in many regards were counterintuitive,
especially for the sickest children [5, 8]. Central to this success has been the ability to
recognise the imperative for correcting cellular functionality in order to improve appetite
by correcting deficiencies of nutrients, such as potassium or zinc while limiting the
therapeutic use of iron, before attempting to address the correction of a deficit in body
composition as marked by anthropometry. The rebalancing of emphasis on the relative
importance of energy and protein intake at different phases of treatment was critical to
this changed perception, as was recognition of the need to correct specific deficiencies
and deficits for a range of nutrients [5, 8]. Scrimshaw drew attention to the critical role
played by the stress of infection and how this might increase losses of specific nutrients,
such as potassium, phosphorus or zinc, and hence enhanced nutritional vulnerability,
thereby enabling the condition to run an aggressively more lethal course in those already
malnourished [4, 5, 25]. Ultimately, both the nurturing viewpoint emphasised by
Williams and the harder scientific perspective favoured by Waterlow feature in
appropriate care and are reflected in the WHO 10 point guidelines for the care of children
with severe acute malnutrition [23].

During the 1960s and 1970s, the debate around whether or not it was best to manage
children in hospital or in the community raged, but the importance of being able to
identify children at risk and direct them to appropriate care was never in dispute [26].
Given restricted access to hospitals, Morley placed justifiable emphasis on approaches
that could operate at the community level by “doing simple things well”. By developing
effective screening of children using assessment in the community, he showed how
worthwhile progress could be made [27]. At the same time, placing emphasis on greater
household food security had an important part to play. Sen placed emphasis on the
important social and economic implications of ensuring food availability, but also drew
attention to the importance of food distribution, with appropriate attention being given to
both food quality and food quantity [9].

Thus, community based care is critically dependent upon the ability to identify those who
are already sick, but also has to pay special attention to those who are particularly
vulnerable and at high risk of mortality. Abnormal anthropometry marks the result of a
period of poor food intake. When carried out well, the use and application of
anthropometry can play an invaluable role in ordering the delivery of services in such
cases. A conceptually simple study carried out in Jamaica showed that the use of regular
anthropometry in young children made it possible to identify and manage those already
malnourished, as well as identify those at increased risk, and offer care to prevent further
deterioration with clear benefit in the first year and sustained benefit over the next three
years. Together, this combined approach substantially reduced the vulnerability of this
population [28, 29]. At the time, these investigators noted that different children were
identified when their anthropometric risk was based upon MUAC compared with when it
was based upon weight for height [29]. It has remained an open question as to what this
difference represented, and what might be the implications for care and outcome.
By 1981, the WHO were able to offer guidelines for the treatment of severe malnutrition
that, when followed, could result in substantial reductions in mortality. However, in
practice, the advice was difficult to follow and required skills and capabilities that are not
usually found in clinical paediatric services nor in clinics where malnourished children
most usually present, if they were present at all [29]. The practicalities of identifying
children at risk through screening with the use of MUAC and the ready availability of
effective therapeutic foods, first developed for practical use in emergencies, changed this
landscape completely [8, 13, 14, 15, 16]. For the first time, the integrated management of
severe acute malnutrition was made practical, by ensuring a more secure diagnosis
associated with an effective therapeutic intervention [15, 16]. The sickest children with
severe malnutrition and complications are most effectively managed in clinical facilities.
The greater proportion of children who have severe acute malnutrition are without
complications and are better managed under supervision in an outpatient clinic
environment. Those identified as affected by moderate malnutrition are still at some risk,
but are less vulnerable and can be securely managed in a well organised community
outreach programme [30, 31]. The enormous progress in developing these capabilities
and their application in practice is a great credit to those thought leaders, scientists, and
practitioners who have ensured that a problem that at one time seemed intractable now
comes within the grasp of manageable.

Every success throws up another series of problems and the three papers in this issue, by
Grellety and Golden, identify and explore one such concern. As alluded to above, there is
evidence from a wide range of populations showing that those identified as being
severely malnourished based upon MUAC as the anthropometric indicator are often
different from those identified as being severely malnourished based on weight for height
[32]. In other words, the two indicators do not necessarily identify the same children.
This is of considerable importance for the delivery of services. There are choices that
have to be made and pragmatically, the simplest approach that gives a workable solution
is usually preferable [15, 16]. It is based on this premise that the adoption and use of
MUAC has enabled effective care to be brought to many vulnerable children and in that
way, saved many lives. The more challenging assessment and quality assurance based
upon the determination of weight for height requires more complex instrumentation with
an associated need for maintenance, together with a skill and capability from staff that is
challenging in many situations. When direct comparisons have been drawn between the
two measures in identifying risk, the use of MUAC has appeared to be the most reliable
[10]. However, over the recent past, as the delivery of improved care has been more
widely available in many more centres, and with better quality measurements, concerns
have been raised. In practice, health practitioners, particularly those working in hospital-
based facilities, have had an increasing concern that they might miss the identification of
the need for special care in children who appear vulnerable based upon a measurement of
weight for height, but who have not been identified as being at risk based upon MUAC.
Thus, there has been concern and debate around proposals to use MUAC as the sole
screening tool.
Grellety and Golden have been active participants on one side of this debate. On the other
has been a group of highly regarded clinicians with considerable experience in the
identification and care of malnourished children, especially in the community. Both sides
have made substantial contributions to our understanding and the practical delivery of
effective care in the most difficult of circumstances. The experience and insights offered
by both sides are to be respected. The three papers in this issue from Grellety and Golden
offer their most recent perspective on the problem [1, 2, 3]. They have sought to bring
together a considerable literature that captures the experience of using the different
measures to identify and diagnose the different phenotypes embraced within the term
severe acute malnutrition, and the mortality related to each of the different clinical
syndromes of severe acute malnutrition: kwashiorkor, marasmus, and marasmic-
kwashiorkor. Their analysis suggests that earlier interpretations of the available data have
within them statistical insecurities that in their adoption and application have led to
unacceptable mortality in children. This is because by only assessing children on the
basis of MUAC, there would have been a failure to identify and treat children who would
have been identified as vulnerable on the basis of weight for height. As they state, if this
insecure interpretation of the risks involved is not addressed, it can have serious
implications that should be taken into account in terms of policy and practice.

Further, these observations and their interpretation sets a great challenge to the scientific
and clinical community to revisit our understanding of the relationship between measures
of body composition and the changes in pathophysiological function that relate directly to
adverse risk for the different malnutrition phenotypes [4, 5]. There is the need to relate
molecular, cellular and tissue changes, alterations in inflammatory and immune
competence, and the nature of the inter-relationship with a modified microbiome to those
anthropometric or other measures of body composition that have been used to
characterise risk. How these relate to actual risk and respond to different care options
marks a new agenda for nutrition research and child health. Modern investigative
approaches, if properly deployed, offer tremendous opportunity for making progress in
this regard. The knowledge and understanding that could come from work of this kind
would provide a refinement of our appreciation of human biology that would contribute
directly to a better understanding of the nature of the double burden of malnutrition. This
has special resonance for the current epidemic of non-communicable disease that is
sweeping the globe and is most readily marked by alterations in body composition,
conveniently characterised as obesity. There is a relationship between the factors that
determine the pattern of tissue mobilisation and weight loss during the development of
malnutrition and the factors that enable the pattern of nutrient partitioning and tissue
deposition during recovery from a period of challenged nutrition. The determinants of the
absolute amounts and relative proportions for the net deposition for length/height, lean
mass, and fat mass are inadequately understood at all ages and stages of life. Their
elucidation is central to the challenge for modern nutritional science and, in fact,
represents a major scientific uncertainty of direct importance for ill-health and its
management across all populations [7, 12].
Structuring the debate around these considerations and using the information that has
been generated during the treatment of severe childhood malnutrition is of immediate
practical value, but also provides an important and critical bridge between the nutritional
science of the twentieth century and that needed for the twenty first century.